Staff contributed to the death of a Jewish immigrant - who died by taking an overdose while awaiting deporation after he repeatedly threatened to do so - by failing to properly communicate about this or his symptoms, an inquest has found.

Amir Siman-Tov, a 41-year-old who was originally from Morocco, was being held at Colnbrook Immigration Removal Centre near Heathrow when he died in the early hours of February 17, 2016, having ingested painkillers the day before.

A jury at West London Coroner’s Court has returned a verdict of death by misadventure, noting that “inadequate information sharing” led to missed opportunities to prevent him taking an overdose “despite Mr Siman-Tov repeatedly stating his intention to do so”.

On the morning before his death, a dentention officer witnessed Mr Siman-Tov take a handful of his prescribed painkillers, the court heard.

A doctor from Hillingdon Hospital, where Mr Siman-Tov was taken, told the inquest a psychiatrist at Colnbrook called him and cast doubt over Mr Siman-Tov’s overdose, suggesting he may have only taken “tic tacs.”

Mr Siman-Tov was discharged after a doctor and consultant decided that he was not showing signs of opiate toxicity.

But the custody officers who were to return him to Colnbrook were given no information about how he was assessed, how he should be looked after or what symptoms he might show if his condition worsened.

During the journey back from the hospital, Mr Siman-Tov was repeatedly sick and looked sleepy, according to the custody officers.

After arriving back, they told a nurse he had been sick once. The nurse told the inquest, if he had known that Mr Siman-Tov had vomited repeatedly, this would have been a “red flag” and he would have arranged for him to return to hospital.

The nurse finished his shift at around 7pm and gave a verbal handover to one of the two night nurses.

While the nurse said he expected the night nurses to carry out medical observations every one to two hours, this was not written in the records.

The court heard the night nurses carried out no observations.

One of the nurses attended to Mr Siman-Tov at approximately 9.10pm to give him medication, which included the painkillers had overdosed on, but when he found Mr Siman-Tov asleep he did not disturb him.

It was not until 3.15am that Mr Siman-Tov was found to be unresponsive by custody officers who were supervising him. Paramedics rushed to the scene and pronounced him dead at 4.10am.

The inquest jury concluded that the “failure to provide a discharge summary, inadequate communication at handover and failure to establish an adequate care plan on return” contributed to his death.

They said: “Although Mr Siman-Tov spoke of his intention to self-harm and expressed suicidal ideation this is judged to be a cry for help rather than a desire to deliberately end his life.”

The Court heard how Mr Siman-Tov, who lived with his family in North East London and had a history of mental health problems, was afraid of being in detention and terrified at the prospect of being deported to Morocco.

Ms Hasenson-Gross renewed René Cassin’s call for the introduction of a 28-day time limit on detention.

“It is now time for the Government to listen,” she said.

In a statement, Mr Siman-Tov’s family said: “Amir was loved by his family and his death has been devastating for us. The jury’s conclusions show that he did not wish to die and that if those with responsibility for his care had not failed him, he would be alive today.

"We were shocked to learn that more than three years on, lessons said to have been learned have still not been implemented, and we now call on those involved – the NHS trusts and Mitie – to do so without further delay.

“We also call on the Home Office to end its inhumane policy of indefinite immigration detention which, as Amir’s case shows, ruins lives and has no place in a civilised society.”

Mia Hasenson-Gross, executive director of Jewish human rights group René Cassin said: “This tragic incident once again highlights the lethal policy of indefinite detention. The evidence that detention is harmful is indisputable.

“It robs people of their dignity, their spirit, and, in Amir’s case, their lives. Four years ago, a cross-party group of MPs condemned it as 'expensive, ineffective and unjust'. Four years later, it is still happening.”